LIVER TRANSPLANTATION 20:619 623, 2014 LETTER FROM THE FRONTLINE Techniques for Safe Organ Recovery After Endovascular Aortic and Bariatric Operations Received January 14, 2014; accepted January 23, 2014. TO THE EDITORS: Since Starzl et al. 1 first published on organ recovery techniques, the field has changed in substantial ways. Organs are often recovered by different centers, and this requires more in situ dissection in a setting of competing interests and unfamiliarity among different surgical teams and local operating room staff. These challenges are compounded by a donor population of advanced age and with a higher prevalence of obesity; this makes reoperative fields more common and the difficulties associated with a larger body habitus more relevant. The imbalance between supply and demand makes organ damage even less excusable in modernday recovery operations. It is well recognized that any reoperative field is more complicated than a virgin abdomen. Two specific operations occurring with increasing frequency have the potential to affect the ability to safely perfuse and recover abdominal organs. Approximately 50,000 persons per year undergo elective or urgent abdominal aortic aneurysm repair. Endovascular repair is increasingly considered the first-line treatment for elective repairs, and in each year since 2003, electively performed endovascular repairs have surpassed open approaches. 2 More than 150,000 people per year undergo bariatric operations, including gastric bypass, gastric banding, and sleeve gastrectomy, in the United States. 3 These numbers reflect just 1% of the population eligible for weight-loss surgery. A preoperative plan is critical to a successful operation, and we present 2 techniques for approaching these complex reoperative patients within the normal skill set of a recovering surgeon. ABDOMINAL ORGAN RECOVERY FOLLOWING ENDOVASCULAR ANEURYSM REPAIR An endovascular graft is a covered, self-expanding metal framework that intravascularly bridges the infrarenal aorta and iliac arteries through the aneurysm; newer fenestrated grafts may even cross the renal arteries. Traditional tube grafts used during open aneurysm repair lack a metal infrastructure and are sewn directly to the proximal aorta and distal aorta or iliacs. This is done after the aneurysm is opened, so there is no false lumen. These structural and technical contrasts are the basis for potential harm to organ perfusion. The radial strength provided by the metal framework allows proper fixation. In contrast to standard grafts, clamping or finger pinching during cannulation results in crimping and flattening of the endovascular graft (Fig. 1A). This may result in high resistance, no flow of the preservation fluid, or even inability to properly insert the aortic flush cannula. Moreover, the cannula may be inadvertently placed in the native aortic lumen outside the covered endovascular stent (Fig. 1B). Both errors risk poor graft perfusion and loss and require an alternative, safe, and easily reproducible technique in any environment without special equipment. We have used a femoral cutdown with distal ligation, through which a standard 18-Fr nasogastric tube (sump-tied) is passed into the abdominal aorta from the side with the longer iliac graft extension (Fig. 2). The tube is measured on the exterior of the body just proximal to the iliac bifurcation. The contralateral iliac artery with the shorter graft extension is then clamped or tied, the ureter having been previously identified. After cooling, the viscera are recovered in the standard fashion. This technique is not time-consuming, allows excellent perfusion, and does not necessitate a difficult dissection from the graft-related periaortic and iliac inflammation. A supraceliac antegrade cannulation is also acceptable, but this is more technically complicated and may interfere with the chest team. ABDOMINAL ORGAN RECOVERY FOLLOWING WEIGHT-LOSS SURGERY Operative management of obesity is routinely performed laparoscopically; this reduces adhesions to The authors of this article have no conflicts of interest to disclose and received no support for this investigation. The institutional review board of the Columbia University Medical Center does not require the evaluation of such reports. Address reprint requests to Michael D. Kluger, M.D., M.P.H., Department of Surgery, New York Presbyterian Hospital/Columbia University Medical Center, 161 Fort Washington Avenue, 8th Floor, New York, NY 10032. Telephone: 212-305-6514; FAX: 212-305-5992; E-mail: mk2462@cumc.columbia.edu DOI 10.1002/lt.23843 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases VC 2014 American Association for the Study of Liver Diseases.
620 LETTER FROM THE FRONTLINE LIVER TRANSPLANTATION, May 2014 Figure. 1. Aortic flush cannula insertion errors related to endovascular aortic aneurysm repair. (A) Occluding the infrarenal aorta during aortotomy results in irreversible crimping of the metal stent s lumen. This may result in an inadequate flow of the preservation fluid or an inability to insert the aortic flush cannula at all. (B) At the time of aortotomy, the cannula may be inadvertently placed in the native aortic lumen outside the covered stent and may thereby prevent circulation of the preservation solution.
LIVER TRANSPLANTATION, Vol. 20, No. 5, 2014 LETTER FROM THE FRONTLINE 621 Figure. 2. Safe cannulation of the aorta through the femoral artery. A flush cannula can easily be passed through the femoral artery into the proximal aorta without dissection of the stented aortic aneurysm and can thereby prevent the errors illustrated in Fig. 1. the abdominal wall, but because these are foregut operations, the burden of inflammation lies near the celiac axis, left liver, and hepatoduodenal ligament. After Roux-en-Y gastric bypass, the neostomach may become adherent to the underside of the left lateral section, the course of the common hepatic artery, or the hepatoduodenal ligament. These adhesions are typically fixed and vascular. Dissection of the subhepatic space becomes more difficult than usual and places important structures at risk if the field becomes hemorrhagic; there is also the potential for liver decapsulation. This adherent state may be exacerbated after sleeve gastrectomy, with the remnant stomach continuing its native course to the duodenum after partial resection of the body and fundus. Because of the interest in sleeve gastrectomy as a
622 LETTER FROM THE FRONTLINE LIVER TRANSPLANTATION, May 2014 Figure. 3. Technique for liver recovery after gastric surgery. (A) After bariatric surgery, the stomach may be adherent to the underside of the left lateral section, the course of the common hepatic artery, or the hepatoduodenal ligament. An endovascular stapler is used to cordon off the viscera adherent to the subhepatic space. (B) This is followed by wide dissection through the bilateral hypochondriac and lumbar regions in order to protect the celiac axis, superior mesenteric artery, portal vein, and bile duct, which can be dissected from a posterior approach ex vivo after preservation.
LIVER TRANSPLANTATION, Vol. 20, No. 5, 2014 LETTER FROM THE FRONTLINE 623 first-line procedure for morbid obesity or as a rescue procedure after failed gastric banding, the incidence of this procedure is increasing. 4 When we are faced with a difficult field, our preferred approach is to use an endovascular stapler to cordon off the viscera adherent to the liver and/or hepatoduodenal ligament (Fig. 3A). The gastric remnant, Roux and distal afferent limb after gastric bypass, or proximal gastric sleeve after sleeve gastrectomy can then be dissected laterally away from the graft and critical structures in the median. This exposes the bilateral hypochondriac and lumbar areas, where the in situ dissection necessary for removing the liver occurs. By coming through the pancreas widely (which is unlikely to be recovered in these patients) on the left and through the adrenal gland on the right, we protect the celiac axis, superior mesenteric artery, portal vein, and bile duct in the median. None of these key structures need to be identified or dissected in vivo, and this is consistent with Starzl s original technique. Kidneys are dissected and removed in the standard fashion, and the chest team is not affected. With the preserved liver placed facedown, the portal triad, cava, and aorta can be safely dissected from posterior to anterior toward the adherent cordoned-off viscera. 5 The dissection now proceeds through an untouched operative plane in the absence of bleeding (Fig. 3B). In summary, we have presented techniques for preventing organ damage that do not require special expertise or equipment in the setting of 2 operations that are increasingly being performed. Having a preoperative plan for operating on such patients can prevent graft damage. REFERENCES Laurence J. Belin, M.D. Robert C. Neely, M.D. Michael D. Kluger, M.D., M.P.H. Department of Surgery New York Presbyterian Hospital/ Columbia University Medical Center New York, NY 1. Starzl TE, Hakala TR, Shaw BW Jr, Hardesty RL, Rosenthal TJ, Griffith BP, et al. A flexible procedure for multiple cadaveric organ procurement. Surg Gynecol Obstet 1984;158:223-230. 2. Schermerhorn ML, O Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008;358:464-474. 3. American Society for Metabolic & Bariatric Surgery. Fact sheet: metabolic and bariatric surgery. http://s3.amazo- naws.com/publicasmbs/metabolicbariatricsurgeryfact- SheetASMBS2013.pdf. Published May 2013. Accessed October 2013. 4. Braghetto I, Csendes A, Lanzarini E, Papapietro K, Carcamo C, Molina JC. Is laparoscopic sleeve gastrectomy an acceptable primary bariatric procedure in obese patients? Early and 5-year postoperative results. Surg Laparosc Endosc Percutan Tech 2012;22:479-486. 5. Boggi U, Vistoli F, Del Chiaro M, Signori S, Pietrabissa A, Costa A, et al. A simplified technique for the en bloc procurement of abdominal organs that is suitable for pancreas and small-bowel transplantation. Surgery 2004; 135:629-641.